1. Field of the Invention
This invention generally relates to managed healthcare systems and procedures and, more particularly, to healthcare management systems and methods for enhancing patients' health by using existing provider Electronic Medical Records and/or billing data.
2. Description of the Prior Art
When a doctor or other medical “provider” examines or treats a patient, hand-written or electronic data records are generated and maintained in the office of the provider for future reference and treatment of the patient. The examination or treatment is typically followed by presenting the patient or the patient's insurance carrier with an invoice itemizing the services rendered and the procedures performed and the corresponding charges. Typically, arrangements are made for future visits, if necessary, so that additional treatments or procedures can be effected, generally in accordance with accepted medical practices. An insurance carrier or managed care organization (“MCO”) responsible for payment for examinations and/or treatments, receive not only a statement of the charges but a complete breakdown of the treatments or procedures implemented as a backup for the monetary charges. Thus, the insurance companies, at least those that cover insured patients, are provided with extensive diagnostic and treatment information with regard to insured customers.
Insurance companies have obligations, real and/or perceived, in making sure that their customers are being provided with healthcare services that meet accepted medical standards. In an effort to discharge their obligations and establish good track records of patient care, MCO's utilize the billing data including diagnoses (ICD9's) and treatments (CPT's), to establish quality reports required by governmental agencies (i.e. HEDIS—to be discussed later). This data is limited in that it includes only billing data provided by one provider to one patient. It does not include any data provided by another unaffiliated provider or group of providers to the same patient. It does not include any medical or social information known by a provider that may exclude the need or rational for a given procedure or a contraindication for that procedure such as a previous complication thereto.
To supplement the reporting of the MCO's raw diagnostic and treatment data (ICD9 & CPT), and compensate for procedures and diagnosis provided to a single patient by other providers, or paid for by other MCO's whose data is not available to the reporting MCO, insurance companies routinely request additional information from providers. While many providers do cooperate and provide the MCO with the requested reports, many providers do not, or do so hesitantly because of the additional work, effort and expense in generating such reports by the providers and/or by their office staff. This additional monetarily uncompensated burden can create an adversarial relationship between insurers and providers.
As previously suggested, insurance carriers do have raw data they receive when providers submit requests for payments. However insurance companies have been slow to organize and distill such data because of the previously mentioned situation as well as the expense involved. Concerning the most complete collection of data in regards to any individual patient's care, there are no systematic collection procedures that assures that the providers and/or the insurance companies have all the relevant information, other than requests to providers which are frequently ignored, and costly site visits to provider offices and chart reviews by trained nursing personnel, which review is limited to that information about a patient available to a single provider that has or is to be paid for (covered) by that reporting MCO. This is a costly and inefficient method for the MCO's who must provide such data (HEDIS) to establish that they are providing quality health care to their insured, this data to be provided by mandate either to the federal government, health insurance department of state governments, and/or municipal governments.
Numerous patents have been issued covering various aspects of medical care and for handling provider invoices to insurance carriers or MCOs. Many of these patents are concerned with proper billing to the insurance companies and detecting improper bills. Thus, in U.S. Pat. No. 6,826,536 a healthcare billing monitor system for detecting healthcare provider fraud is disclosed. The patent disclosure is not concerned with the continued or ongoing wellness of the patient.
A system and methods for correlating medical procedures to medical billing codes is disclosed in U.S. Pat. No. 5,325,293, in which a system correlates billing codes with planned or performed medical procedures. The patent is primarily concerned with manipulating the raw codes to generate intermediate codes and the system is used to generate invoices.
A network-connected personal medical information and billing system is disclosed in the published U.S. patent application No. 2004/0254816. The method disclosed is used by a medical service provider to document and approve service and billing information substantially contemporaneously with the provision of services. The method also includes the storage of context information for output in connection with billing information.
In U.S. Pat. No. 5,191,522 an integrated group insurance information processing and reporting system is disclosed for processing and supervising a plurality of group insurance accounts. The system provides administration and actuarial functions.
Other patents disclose applications dealing with billing and insurance claims. In U.S. Pat. No. 6,026,363, systems and methods are disclosed for qualitative medical expressions. Typically, a phrase is used to generate a numerical value that represents the likelihood of an event. A database of information about the significance of the existence of a symptom for the diagnosis of a particular disease might then be predicted.
A medical history documentation system and method are disclosed in U.S. Pat. No. 5,704,371, in which information relating to at least one current medical condition of the patient is recorded. A physical examination, diagnosis and a treatment plan is shown.
In U.S. published patent application No. 2005/0065816 a healthcare management information system is disclosed in which a computer program generates a visual compliance display. The compliance obligation is typically received from a healthcare provider, the system automatically determining different compliance obligation levels.
U.S. Pat. No. 7,236,986 discloses a method of providing billing support in a high throughput to computer-aided detection environment, in which billing statements are generated using information relating to patient identification and film images from patients.
Other systems and methods have been disclosed for identification of clinical study candidates, such as the method disclosed in U.S. Pat. No. 5,191,522, in which a system searches electronic medical data to identify a pool of potential study participants. However, while the method may provide a pool of potential study participants for conducting tests and evaluations in connection with a given study it is not intended to directly benefit the wellness of any particular patient.
In U.S. Pat. No. 5,301,105 an all care management system is disclosed. The system integrates with the patient's healthcare provider, bank or other financial institution, insurance company, utilization review or an employer to provide the patient with pre-treatment, treatment and post-treatment healthcare and financial support. While the patent suggests post-treatment procedures, there is a little teaching in the patent of how such post-treatment procedures can or are to be accomplished. Additionally there is no teaching or suggestion in the patent or that billing information be analyzed, by the insurance companies or third-party service centers, for determining, for each patient, all of the services that have been performed on the patient and generating instructions, reminders or suggestions to the patients and/or providers to perform additional procedures, in accordance with well-established and accepted medical protocols, to complete the treatment protocols of the patient in order to assure the continued wellness of the patient.